The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LINDEN OAKS HOSPITAL 852 S WEST STREET NAPERVILLE, IL 60540 Aug. 26, 2015
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 (Pt. #3) of 3 records reviewed of patients on restraint/seclusion, the Hospital failed to ensure that a notice of restriction of rights was completed as required by policy.

Findings include:

1. The Restraint log for the Adult unit from 1/1/15 to 8/20/15 was reviewed on 8/25/15. The log included Pt. #3 being placed on a therapeutic hold on 7/27/15, for a duration of 7 minutes.

2. The clinical record for Pt. #3 was reviewed on 8/25/15. Pt. #3 was an [AGE] year old male admitted on [DATE] with a diagnosis of depression. The clinical record included an order for the Therapeutic hold, however a Restriction of Rights form was not completed as required.

3. The Hospital policy titled, "Restraint and Seclusion" (rev 5/12/15) required, "Definition-Restraint-Any method, physical or mechanical...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...." Documentation...A restriction of Rights form is completed...The patient is advised of the rights to have a person of their choosing notified of the restraint/seclusion."

4. The above finding was discussed with the Adult unit Nurse Manager on 8/25/15 at approximately 2:30 PM, who stated that a restriction of rights notice form should have been completed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document reviews, and interview it was determined that for 1(Pt. #2) of 3 records reviewed for restraints and seclusions, the Hospital failed to ensure orders were obtained for initiating and renewing patient seclusion.

1. The clinical record for Pt. #2 was reviewed on 8/25/15. Pt. #2 was a [AGE] year old male admitted on [DATE] with a diagnoses of bipolar affective disorder, anxiety and mood disorder. The clinical record contained a "Notice Regarding Restricted Rights of Individuals" indicating that Pt. #2 was placed in seclusion on 8/17/15, at 12:15 PM and continued till 7:00 PM. However, the record lacked a physician's order for initiating the seclusion on 8/17/15 at 12:15 PM and a renewal order, to continue with the seclusion until 7:00 PM.

2. The Hospital policy titled, " Restraint and Seclusion" (rev 5/12/15) required, "When restraint/seclusion is required...an order is obtained from the attending psychiatrist within 1 hour of the initiation. The order must be signed within the EMR within 24 hours... Orders are renewed by the psychiatrist as follows: ...4 hours for adult 18 years and older...."

3. The above findings were discussed with the Manager of the Adult unit during an interview on 8/25/15 at approximately 2:45 PM, who stated that an order and renewal order should have been obtained and written for Pt. #2's seclusion from 12:15 PM to 7:00 PM on 8/17/15.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document reviews, and interview it was determined that for 1 of 3 (Pt #2) records reviewed for restraints or seclusions, the Hospital failed to ensure a 1 hour face to face evaluation was conducted.

1. The clinical record for Pt. #2 was reviewed on 8/25/15. Pt. #2 was a [AGE] year old male admitted on [DATE] with diagnoses of bipolar affective disorder, anxiety and mood disorder. The clinical record contained a "Notice Regarding Restricted Rights of Individuals" indicating that Pt. #2 was placed in seclusion on 8/17/15, at 12:15 PM until 7:00 PM. However, the record lacked a face to face evaluation within 1 hour of the implementation.

2. The Hospital policy titled, " Restraint and Seclusion" (rev 5/12/15) required, "A physician or RN in a supervisory position examines the patient within 1 hour of implementation...this evaluation includes: 1. Evaluation of patients' immediate situation, 2. The patient's reaction to the intervention, 3. The patients medical and behavioral condition, 4. The need to continue or terminate the restraint/seclusion.

3. The above finding was discussed with the Manager of the Adult unit during an interview on 8/25/15 at approximately 2:45 PM, who stated that a face to face evaluation is conducted within 1 hour of restraint/seclusion.